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CD <br />CO <br />0 - <br />CO <br />IMMININNEENI <br />11 •. 1 1..■111 <br />r <br />Affidavit of Affixture <br />ti1 Fora Mobile Home With a <br />DEPARTMENT OF MOTOR V CLES Nebraska Certificate of Title <br />and cancellation of Certificate of Title from each lien holder must be attached to this 0 <br />, Affidavit. This completed t must be presented to the County Treasurer along with the Certificate of Title in the d <br />ro county where the real property is sated for cancellation of the existing Certificate of Title to occur. <br />A filing fee is required per §33 -109 and §33 -112. <br />Mobile Home Owner #1 <br />Name Sarah Melnick <br />Address 02-2 "S' 60 10 r1 <br />City, State Zip ADP Pk& 11 /1/ - a a <br />Mobile Home Owner #2 <br />Name <br />Address <br />City, State Zip <br />rn <br />,' T 0 4 . { r"' z_) <br />... , r — <br />µ 1 a Co <br />.,$ c <br />r 1 <br />CO (1 <br />Attach additional Affidavit(s) if more than 2 owners. <br />Owner of real estate ❑ Leasing real estate <br />CD <br />C) <br />CD <br />r=t <br />CZ) <br />CO <br />Mobile Home Description: Year 2002 Make Patriot <br />Vehicle Identification Number VP9347BAI N <br />Title Number <br />Model N R 11 O R <br />If two Vehicle Identification Numbers are present, an Affidavit must be completed for each number. <br />Real Estate Owner #1 <br />Name Sarah Melnick <br />Address ..? . .r S, v l / <br />City, State, Zip Of s P 4 a /ye td", S 2 <br />Real Estate Owner #2 <br />Attach additional Affidavit(s) if more than 2 entities are to be notified. <br />Name <br />Address <br />City, State, Zip <br />Copy of Notice of Cancellation shall be provided to all owners listed above and the following financial institution(s): <br />Name <br />Address <br />City, State, Zip <br />Attach additional Affidavit(s) if more than 2 entities are to be notified <br />Name <br />Address <br />City, State, Zip <br />1 of 3 <br />Affidavit of Affixture For a Mobile Home With a Nebraska Certificate of Title <br />6/2017 <br />rvi <br />